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Full text of "Typhoid fever : its cause and prevention"

Tl North Carolina State Library. N. C. 

> ;T"3 Rslei9h ' 

TYPHOID FEVER 



ITS CAUSE AND 
PREVENTION 



PREPARED BY 

The North Carolina State Board of Health 

RALEIGH, N. C. 



PRESSES OF 

EDWARDS & BROUGHTON PRINTING CO. 

state printers 



TYPHOID FEVER 



ITS CAUSE AND 
PREVENTION 



PREPARED BY 

The North Carolina State Board of Health 

RALEIGH. N. C. 



presses of 

Edwards & Broughton Printing Co. 

state printers 



Digitized by the Internet Archive 

in 2010 with funding from 
State Library of North Carolina 



http://www.archive.org/details/typhoidfeveritscOOnort 



TYPHOID FEVER— ITS CAUSE AND 
PREVENTION 



HISTORICAL. 

The word typhoid means a stupor-like fever. The disease was clearly 
separated from typhus fever, a disease which resembles it somewhat, in the 
forties of the last century. This latter disease, typhus fever, is now almost 
extinct. The cause of typhoid fever is a small germ called the typhoid germ 
or bacillus typhosus. This germ was discovered by Eberth in 1880. 

GEOGRAPHICAL. 

Typhoid fever is one of the most widespread of the infectious diseases. 
"It occurs in the tropics and in far northern and southern latitudes, at sea- 
level and in the mountains, in the city and in the country, and practically 
wherever man may go and local conditions do not prevent the dissemination 
of the disease. The B. typhosus has about the same limits of latitude and 
longitude as man himself, and no country or race is known to be immune 
from the disease." * While this is true, it is also a fact that the frequency 
of the disease in different countries varies considerably. A temperature of 
80 to 95 degrees does, by increasing germ growth and more particularly by 
bringing flies, increase the number of cases of typhoid. With the summer come 
flies and typhoid. With the exception of variations in frequency caused by 
differences in temperature in different parts of the world, all races are equally 
liable to this curse of filth. Dr. Osier's saying, "Typhoid fever is the best 
index to the sanitary intelligence of a community," is axiomatic with 
sanitarians. 

IMPORTANCE OF THE DISEASE. 

Of every 100,000 inhabitants of the United States, 46.5 die every year 
from typhoid fever. To appreciate what this means, we may compare it with 
the typhoid death rate in other countries. The death rate per 100,000 popu- 
lation in Scotland is 6.2; in Germany, 7.6; in England and Wales, 11.2; in 
Belgium, 16.2; in Austria, 19.9; in Hungary, 28.3; in Italy, 35.2; in the United 
States, 46.5. Differences in climate, soil and geographical peculiarities are 
not sufficient to explain these variations in death rates. Their explanation 
is dependent upon differences in the sanitary intelligence of the people in 
these countries. We lose 35,000 lives every year in the United States from 
typhoid fever; in addition we have 350,000 others sick on an average of six 
weeks apiece. Certainly the typhoid problem is a grave concern for our 
country to grapple with. 

But what does it mean, not to the country, state or community, but to 
you, just you? We speak now to the man whose bonds of sympathy with the 
general mass of humanity are so few, so short, and so attenuated that he is 
concerned for himself and family only; his public spirit finds its fullest ex- 
pression in his unuttered prayer — 

"God bless me and my wife, 
My son John and his wife, — 
Us four and no more." 



Osier's Modern Medicine, Vol. II. 



It means that if you come within the rule of probability, if your life is 
governed by rules instead of exceptions, you will have one chance out of sis 
to have this disease, and one chance out of sixty to die with it; that if you 
have a family of a wife and four children, according to the rule, one of them 
will have this disease, and the chance is one out of six for one of your family 
to die with the disease. 

I have in mind, as I write, a family living on a site where no case of 
typhoid has occurred in the fifty years in which this place has been used as a 
home. The head of this family had frequently boasted of the freedom of the 
place and family from the disease. The country isolation of this home, the 
surface contour of the yard and surroundings, the depth of the well, and the 
unknown occurrence of the disease on that hill might persuade one to regard 
this family as an exception to the rule of one case of typhoid to six of a 
family; might persuade the head of such a family to feel a bit indifferent to 
the typhoid problem. The children are growing up, like all children, one by 
one, they are leaving this place of safety and coming under the general rules 
which govern their kind. The two oldest, the two that have been away from 
home the longest, have both had typhoid, giving, even in that apparently 
typhoid-free family, the rule more than its dues, 1 out of 5 instead of 1 out of 
6. As the other children grow up and become a part of the world, they too 
will come within the jurisdiction of the rule of 1 to 6. As the head of this, 
and the heads of all families, are interested in their children and their grand- 
children's children, they will do their duty, that is, something against this 
great foe of their fireside and their race. 

THE INDIVIDUAL'S DUTY TO THE TYPHOID PROBLEM. 

And what is the least you can do in the fight? "Knowledge is power," is 
the power that puts to flight this unseen foe, the typhoid germ, which in six 
years kills more people than were killed on both sides during the four years 
of civil war; and which causes the loss of $350,000,000 to the United States 
every year. Equip yourself for your part in this fight with the knowledge of 
how the disease picks off its victims, and how it may be prevented, and then, 
according to your circumstances, use this knowledge. 

Cause. 

THE GERM. 

A germ, the bacillus typhosus, causes every case of typhoid; and without 
it no case would ever occur. The proof of this is that every case with the 
well-known symptoms of this disease, when bacteriologically examined, re- 
veals this particular germ; that measures known to destroy this germ will 
prevent the occurrence of the disease; that all epidemics successfully com- 
bated are controlled by measures directed against this germ; and that this 
germ injected into chimpanzees will produce the disease as it occurs in man. 
This germ is rod-shaped, about 1-15,000 of an inch long and half as thick .is 
it is long. Seen under the high power of the microscope, it is very active, 
swimming like a snake. 

ROUTE OF INFECTION. 

The natural home of this germ is the intestine of one who is in the early 
stage of the disease, or who is in an attack of the disease, or one who has 



previously suffered a recognized or unrecognized attack of typhoid. The in- 
testine is invariably the starting point of every case of typhoid. From the 
intestine of the infected it must reach the intestine of the uninfected to 
produce a second case. To make his trip it must first gain exit from the 
body harboring it. It gains this exit either in the stools from the bowels or 
in the urine from the bladder. Once out of the body, it may find its next 
victim by one of the following routes: 

WATER ROUTE. 

If a stool is thrown out upon the ground without having been first dis- 
infected, it may be washed by the rains into the opening of a near-by well or 
into a brook or stream from which many people are supplied with water. 




(Reproduction from Ritchie's Primer of Sanitation. Copyright, 1909, 
by World Book Company, publishers, Yonkers-on-Hudson, New York.) 

See Figs. 1, 2 and 3. Or, the stool may become dissolved and percolate 
through the interstices of the soil, carrying with it the typhoid germs, until 
it reaches the water in a near-by well. See Fig. 4. 

Right here the importance of definitely determining the vitality of ty- 
phoid germs under external conditions — away from their natural home, the 
human intestine — becomes apparent. If the typhoid germ dies quickly in 
soil or in water, then the water route is much less dangerous than it would 
be if this germ lived weeks, months or years under these external conditions. 
They may live in ordinary soil several months. If in soil kept moist by a 
leaking drain, or in soil frequently moistened with beef soup, they will live 
two months. In fecal matter they will live longer than in ordinary soil. 
They have been found in garden soil which had been fertilized fourteen days 
previously with the contents of a five-months-old privy vault. The germ will 
live three months in distilled water. Its life in other water depends upon a 
number of variable factors, such as movement, light, chemical substances, 
and particularly upon the presence or absence of other bacteria or germs, 
many of which are inimical to the typhoid germ. They have been found 
alive eight days in drinking water, and they will very probably live a much 
longer time in the mud and scrapings from wells and reservoirs. Evidence 
indicates that these germs may live four or five days and travel a distance 



6 



of eighty-five miles in river water. They have been known to live three 
months in ice. About 40 per cent of all typhoid in the United States is 
believed to be water-borne. 

Pacts, proving the relation of water to the disease, are variations in the 
frequency of typhoid in two cities under identical conditions with the excep- 
tion of water supply, which is taken from different sources; variation in fre- 
quency among the inhabitants of a single town which has two different 
water supplies; variations in the frequency of the disease in the same town 
before and after the installation of a filter, which is known to remove about 
98 per cent of the germs in water. Hamburg, Germany, taking her water 
supply from the Elbe River close to where the city sewers emptied, had, be- 
tween 1885 and 1888, 15.800 cases of typhoid. Wandsbeck, a neighboring city, 




^~sg&$r. arc 







Fig. 2. Bad top. Fig. 3. Good top. 

(Reproduced from Ritchie's Primer of Sanitation. Copyright, 1903, by World Book 
Company, publishers, Yonkers-on-Hudson, New York.) 

with a different water supply, was practically free from the disease. In 1901 
an epidemic occurred in New Haven, Connecticut, which resulted in 514 cases 
with 72 deaths. New Haven had five distinct water supplies. On one of 
these systems the source of the infection was found in a patient who deposited 
the undisinfected stool where it was washed into the water supply. Ninety- 
six per cent of all the cases of this epidemic occurred in those using the pol- 
luted water supply. Only 4 per cent occurred in those using water from the 
other four systems. The effect of filtration, a process that removes approxi- 
mately 98 per cent of all the germs contained in water, is well shown in a 
number of instances. Paris put in a public filter and her typhoid death rate 
fell from 142 to only 17 per 100,000. Munich put in a filter and reduced a 
typhoid death rate from 291 to 10 per 100,000. Hamburg filtered her water 
supply and reduced her typhoid death rate from 40 to 7.2 per 100,000. Law- 
rence, Massachusetts, put in a public filter and her typhoid death rate 
dropped from 121 to 26 per 100,000. Ten cities of New York — Albany, Bing- 
hampton, Elmira, Horwell, Hudson, Ithaca, Rensselaer, Shenectady, and 
Troy — filtered their water and reduced a previous death rate 56 per cent. 
Evidence showing the relation of impure water to typhoid fever could be 
almost indefinitely continued, but enough has been said to sustain the re- 
lationship. 








pv*v.-. tin I-,- 

feife:' 1 ' 1 ' 
Pi' 




FOOD ROUTE. 

As cooking kills all germs, food containing typhoid germs must be food 
that has not been cooked, that is, raw food, or food that has been cooked and 
then handled by some one whose hands are contaminated with these germs. 
Naturally, the raw foods will be most likely to contain the germs. As milk is, 
by all odds, the commonest raw food consumed, and as in cities it is handled 
by a large number of people before reaching the consumer, it is more often 
the means of transmission than all other raw foods combined. From 15 to 20 
per cent of all epidemics are due to milk transmission. Occasionally, other 
raw foods, such as oysters, clams, celery, water-cress, lettuce, onions, turnips, 
and ice, may serve as the medium of transmission. Probably from 2 to 5 
per cent of the total number of cases are carried in this way. All of these 
raw foods — milk included — become the means of transmission by some one 
with the disease, or who has had the disease and still carries the poison, 
having handled the food before it is swallowed; or by the handling of the 
food by some one who at the time is associated with a case of the disease; or 
by the vessels in which the food is contained having been washed in water 
that has become contaminated in some of the various ways mentioned under 
water route; or, finally, by flies carrying the infectious material to the food 
over which they crawl. 

There are a number of epidemics clearly traceable to milk. Character- 
istic of milk epidemics is the fact that when the town suffering has several 
dairies, over 90 per cent, often 95, 97, or even 98 per cent, of the cases will be 
on a single dairyman's route; the cases occur almost solely in the consumers 
of milk, and therefore the cases are more frequent in children than in adults, 
and more frequent among the better classes than the poorer classes, as the 
latter use less milk than the former; investigation nearly always reveals a 
case of the disease with which some one of the dairy employees is more or 
less closely associated; examination of the water supply finds the water pure. 
Lastly, milk epidemics are very rapid in onset, a large percentage of the 
cases coming down in the first week of the epidemic, whereas epidemics due 
to water are slower, more gradual, in onset. 

CONTACT INFECTION. 

By which we mean the contamination of an attendant's hands with micro- 
scopic bits of saliva, urine or stool, through the handling of the body, or some- 
thing that has touched the body, of a typhoid patient. The poison is then 
transferred to the mouth or food that is later eaten. This would be avoided 
if the attendants on typhoid patients would carefully wash the hands in an 
antiseptic wash after handling the patient or his belongings, or before they 
put their hands or something handled by them into their mouth. About 5 
per cent of all cases are contracted in this way. The danger from this form 
of infection is directly proportionate to the sanitary intelligence and careful- 
ness of those caring for the sick. The danger through contact infection is 
especially great where large numbers are thrown together, as in jafls, and 
particularly in military encampments. Among 5,000 Boer prisoners held by 
the British army in the Ceylon hills, 700 of them had typhoid fever in three 
months. The guards, using the same water and food supply, escaped the 
disease. In private homes, statistics, based on 13.000 cases, show that 85 per 



9 

cent of the cases occurred in houses where there was but one case. This fact 
should never be made an excuse for sanitary negligence in nursing the 
disease. 

FLY ROUTE. 

Look at Fig. 6; notice the hairy, bristly foot of the fly, to which sticky 
material clings in abundance. See Fig. 7 and Fig. 8, and remember that 
when he leaves these places to enter the kitchen or dining room to light on 
your food he doesn't wipe Ms feet. 

Remember again, that in the open privy— the chief loafing place of the fly 
between meals— the germs of typhoid fever and other intestinal diseases are 




Fig. 5. (By Courtesy of Good Housekeeping Magazine.) 

deposited. A patient usually remains up and about a week or ten days 
before going to bed with typhoid. During this time the patient passes, in his 
stools, millions of typhoid germs. Again, the Germans have shown that 
about 3 per cent of recovered cases still continue to harbor in their intes- 
tines and pass in their stools typhoid germs. Who can tell when some one 
in the early stages of the disease, or some one who has recovered from the 
disease and still carries the poison, will deposit in the open privy of your 
own back yard or your neighbor's open privy, if you live in town, some of 
these seed of disease and death which the flies will carry into your home? 
See Fig. 8. 

When the United States concentrated her troops at Chickamauga in 1898, 
L-pseparatory to the invasion of Cuba, some of the men arriving at camp were 



10 

in the early stages of typhoid fever. Before going to bed with the disease, 
these soldiers deposited their infected stools in open ditches or latrines. 
Soon typhoid began to develop rapidly among the soldiers. The water supply 
of the camp was examined and found pure. The milk supply was likewise 
found above suspicion. It was noticed that the disease occurred almost ex- 




Fig. 6. (Courtesy Florida State Board of Health.) 

clusively in the soldiers who took their meals in the mess-halls that were 
unscreened. It was further noticed that the disease was most prevalent 
among the soldiers who ate in the mess-halls closest to the open latrines. As 
flies were abundant at the same time, this incriminating evidence pointed 
more and more clearly to that pest. Flour and lime were sprinkled upon the 
excreta in the latrines and a short time thereafter flies were found in the 
mess-halls covered with white powder. This strongly circumstantial proof 



11 

was made conclusive when bacteriological examination of captured flies found 
myriads of typhoid germs both in and on their bodies. 

Among 107,000 American soldiers there were 20,100 cases of typhoid and 




il&k. 



"WHERE THE FLIES 
COME FROM 




WHERE' THE 
TE1E5 GO 



Fig. 7. 



Fro. 8. 



(Courtesy Florida State Board of Health.) 



1,580 deaths as a result of fly infection. Since the study of the fly in con- 
nection with this outbreak, numerous and independent workers have placed 
beyond question the deadly role of the fly in this disease. 



12 




13 

Prevention of Typhoid Fever. 

Typhoid fever is a preventable disease. For every case of this disease, 
for every death from this disease, some one is responsible, 

PROTECT THE WATER SUPPLY. 

It has already been stated that 40 per cent of typhoid fever is water- 
borne. Water supplies may be classed as public and private. The first sup- 
plies water to a large number of people and is subject to public control; the 
second supplies one or two or three families and is subject to individual con- 
trol. When either a public or a private water supply becomes contaminated 
with typhoid germs and causes fever, those in charge of the care of the water 
are responsible. 

If it is a public water supply infected, either the State Board of Health, 
the Legislature, or the courts are responsible. The State Board of Health is 
responsible, first, when laws adequate to have prevented the infection exist 
but have not been enforced by the Board. Second, when infection is due to 
the non-existence of laws which the State Board of Health has never re- 
quested the Legislature to pass. The Legislature, representing the people, 
is responsible when they have refused to enact laws requested by the State 
Board of Health which would have prevented the pollution of the water 
supply. The courts are responsible for the pollution of a public water supply 
and the sickness and death arising therefrom when their attention is called 
by the State Board of Health to an infringement of a law protecting the 
purity of a water supply, and when they fail to prosecute the guilty party or 
parties for said infringement. The duty of the citizen to public water sup- 
plies is to demand an explanation of these public servants in case of water- 
borne diseases affecting a community using a public water supply. Where 
inefficiency is found, the ballot and civic influence should be used to remove 
the inefficient official. 

If a private supply is polluted, the individual owning or controlling it is 
responsible for sickness and death resulting therefrom. The individual may 
be ignorant, but his ignorance is a fault — a sin — a grievous sin when it costs 
a life. 

If the individual uses water from a cistern, caught from the roof, he will 
have no water-borne disease. 

If he uses a spring or well, it should be so situated with reference to 
privies or cesspools that no surface drainage can reach it; that is, the surface 
water should not run from a privy or cesspool toward a spring. The surface 
opening of every water supply should be either on higher ground than the 
privy or cesspool or separated from it by a well-marked ridge. The percola- 
tion through the soil of fecal, contaminating material (see Fig. 4) is to be 
prevented by making the privy after plans and specifications of the North 
Carolina Standard Sanitary Privy (see April, 1910, Bulletin). In no case 
should the well and the privy be closer than 50 feet, and unless the standard 
privy is used, the distance should be at least 200 feet. 

PREVENT FOOD INFECTION. 

Do not allow any one in any way associated with a case of typhoid to 
handle the food at any stage of its preparation unless you are positively sure 



14 

that the following precautions are taken: First, that the outer clothing is 
changed in going from the sick room to the kitchen or dining room. Second, 
that the hands are disinfected in going from the sick room to the dining 
room or kitchen, in disinfecting solution No. 1 (see page 15). 

Remember the danger of transmission of typhoid by some one who years 
previously has had the disease, has recovered from all the symptoms and 
effects, but. who still carries the germs in his intestines, passes them in 
the stools or urine, and frequently through pollution has them on their hands. 
People who have recovered from the disease ten to fifty years before have 
been known to transmit the disease in this way. These people are known as 
"typhoid carriers." As already stated, about 3 per cent of all who recover 
from the disease continue to carry the germs — to be "typhoid carriers." The 
most famous of these "typhoid carriers" is a cook in New York City, to whom 
twenty-eight cases of typhoid were traced. This is "Typhoid Mary." The 
health department examined her stools and found them swarming with 
typhoid germs. 

Whenever a case of typhoid fever occurs in a household where other 
possible sources of infection can be ruled out, those having to do with the 
preparation of the food should be thought of as possible carriers. 

PREVENT CONTACT INFECTION. 

By always washing the hands in disinfecting solution No. 1 after touch- 
ing the patient, his excretions, or any of his belongings. No one should use 
a patient's clothing or bed clothing until they are first soaked for two hours 
in disinfecting solution No. 1. 

PREVENT THE TRANSMISSION OF THE DISEASE BY FLIES. 

Of course the ideal method of preventing the transmission of the disease 
by flies is to get rid of the flies. Cities and towns will certainly accomplish 
this at an early date. As 99 per cent of flies are bred in horse manure, the 
proper care of horse stables means fly extinction. Horse stables could receive 
this proper care if boards of aldermen would pass an ordinance requiring the 
licensing of all stables. 

One condition on which license would be granted would be proper con- 
struction of the stable; this would mean a good tight floor in every 
stable. Another condition on which license would be granted would be a 
license fee from each stable owner, enough to compensate the town for having 
each stable thoroughly cleaned once a week. The town or city can not trust 
the stable owners to keep the stables clean. This must be done by the town 
under the direction of the health department. 

In rural districts fly breeding is more difficult to prevent. Dr. L. O. 
Howard says that "people living in agricultural communities will probably 
never be rid of this pest." This is due to the fact that the accumulation of 
manure for its fertilizing property does not enter into the consideration of the 
fly problem with the urban house owner as it does with the farmer. Not 
until some cheap chemical solution, which sprinkled over the manure in 
small amounts will kill the fly eggs and larva?, is discovered, will the pre- 
vention of fly breeding in the country be attained in a practical form. 

But, if we can not prevent fly breeding, we can prevent the flies from 
carrying the contents of the open privy to our food in the dining room and 



15 

kitchen. We can have the sanitary privy described in the April, 1910, Bulletin. 
This sanitary convenience does not cost more than six or eight dollars. 
Plans and specifications for such a structure will be furnished by the State 
Board of Health to any citizen without cost. No town should permit the use 
of any other kind of privy. This could easily be accomplished by an ordi- 
nance similar to the one suggested above for the regulation of horse stables. 
In addition to the fly-proof privy, every dining room and kitchen should 
be effectually screened against flies. The few that enter should be caught on 
fly paper. Remember, flies mean filth, and the number of flies in any house 
or town is the best index to its cleanliness. 

THOROUGH DISINFECTION OF TYPHOID DISCHARGES. 

If all infected discharges — the stools and urine — of typhoid patients, were 
thoroughly disinfected before flies lit upon them, or before they were thrown 
out upon the soil to find their way into a private or public water supply, 
there would be no typhoid. As a matter of fact, it is impossible to disinfect 
all such discharges, because in the first week or ten days of the disease and 
in many cases for weeks, months, and years after an attack, the patient, 
ivilhout knoioing it, passes stools and urine infected with typhoid germs. 
It is for this reason that a sanitary privy where all discharges will be kept 
from flies, is the most important preventive measure. Nevertheless, many 
cases would be prevented if discharges were placed in solution No. 2 (see 
below), covered at once and left standing two hours before being emptied into 
the closet or buried with at least one foot of cover and at least two hundred 
feet away from any well or spring. 

Disinfecting Solutions. 

No. 1. One bichloride tablet to a pint of water, or one teaspoonful of the 
pure chemical to one gallon of water. Add enough ordinary washing blueing 
to color slightly so that no one will drink the solution for water, as it is very 
poisonous. It will keep indefinitely, but should not be stored in a metallic 
vessel. It is to be used for washing hands and soaking infected clothing. 

No. 2. One-third of a pound (about a teacupful) of chloride of lime to 
one gallon of water. Make up fresh each day. Use to disinfect stools and 
urine; one quart of the solution to each stool, and volume for volume for 
urine, thoroughly mix and allow to stand at least one hour before emptying. 

After discussing the matter of the prevention of typhoid by means of 
sanitary measures, the fact remains that in practice it is not always possible 
to prevent it absolutely by this means, and therefore as a still further means 
of prevention, considerable may be accomplished by 

Anti-typhoid Vaccination. 

Within recent years vaccination as a prevention for typhoid has been 
attracting considerable attention, particularly in military circles. As early 
as 1884 we have records of attempts at immunization against typhoid by 
vaccination. These first efforts were not highly successful, but in 1904 
elaborate experiments were made along this line, and since then the results 
obtained have been indeed encouraging. 



16 

While the degree of immunization has not been equal to that obtained 
in the case of vaccination as a prevention for smallpox, yet the following 
results were obtained in the case of 19,314 English soldiers living under 
similar conditions in India in 1909: 

Inoculated. Non-inoculated. 
10,378 8,936 

Cases of typhoid 56 272 

Deaths from typhoid 5 46 

Case rate per 1,000 5.39 30.4 

Case mortality per 100 8.9 16.9 

In other words, the typhoid vaccination reduced the probability of taking 
the disease to about one-sixth, and of those that took the disease, the fatality 
among the typhoid vaccinated patients was only about half that among the 
unvaccinated. Therefore, those that were vaccinated reduced their proba- 
bility of death from typhoid to about one-twelfth of that of the unvaccinated. 

These statistics were taken from army records for the following reasons: 
First, because compulsory vaccination can be, and frequently is, enforced, 
thereby furnishing large numbers of cases; second, because of the greater 
ease and accuracy with which such records may be obtained; and, third, be- 
cause of the greater danger from typhoid to which soldiers are necessarily 
exposed. 

Typhoid vaccine is prepared by making a typhoid culture, or growing a 
large quantity of typhoid bacilli in a substance suited to their rapid growth 
and afterward killing all the bacteria by means of heating the culture or 
growth to a temperature of about 127 degrees F. To make doubly sure that 
no living typhoid germs are left, the culture or growth is then treated with 
an antiseptic solution and sealed in small glass vials. 

The vaccine is then ready for use and is applied by means of a hypo- 
dermic syringe. Three inoculations are usually made in the arm just below 
the surface of the skin. The quantity used for the first dose corresponds to 
about 500,000,000 killed bacilli. In about one-third to one-half the cases the 
first dose produces a slight headache or feeling of uneasiness or indisposi- 
tion a few hours after the inoculation. The inoculations are therefore usu- 
ally made about four o'clock in the afternoon, so that this feeling of indis- 
position comes on after retiring. At the site of the inoculation a red, tender 
area is produced, which disappears in a few days. About ten days after the 
first dose is given the second inoculation is made, and about ten days later 
the third dose is given. The second and third doses are about twice the size 
of the first and contain about 1,000,000,000 killed typhoid bacilli each. In the 
case of the second dose only about one-fourth of the people vaccinated nolo 
any reaction or after effect, and only about every sixth person notices any 
appreciable effect after the third dose. 

Unfortuntely, there is little data at hand to indicate the length of time 
or duration of immunity from typhoid fever as a result of anti-typhoid 
vaccination. It is generally believed, however, that the immunity produced 
is not as effectual and does not last as long as in the case of anti-smallpox 
vaccination. It is generally believed that the immunity lasts for about a 
year, and some think much longer. 

In conclusion, the matter of anti-typhoid vaccination may be briefly 
summed up as follows: 



17 

1. Anti-typhoid vaccination has been applied with great success in the 
reduction of morbidity and mortality, especially in American, German and 
English armies. 

2. The greatest protection or immunity are secured after three inocu- 
lations. 

3. There is no danger from the process when done by a competent 
physician. 

4. Although the duration of immunity is shorter than that secured 
against smallpox, and may not be much over a ye^r, yet anti-typhoid vacci- 
nation is especially applicable to, and should be used by doctors, nurses, stu- 
dents of medicine, soldiers, and all others who are particularly exposed to 
typhoid, especially during an epidemic, or by those living in typhoid-ridden 
places. 

How Cities and Towns Should Control Typhoid. 

TO PREVENT ITS OCCURRENCE. 

First. Have ordinances licensing privies and stables as suggested under 
the transmission of the disease by flies. 

Second. If the town is without a public water supply, require that the 
water supply that was used by every person developing a case of fever be 
examined by the State Laboratory of Hygiene, and, if found polluted, be con- 
demned as a public nuisance under the law for abatement of nuisances. See 
section 12, Public Laws 1911. And, further, that it shall remain a nuisance 
until subsequent analysis by said laboratory shall show its purity. 

Here, I may add by way of explanation, that every typhoid producing 
well or spring is a nuisance, as a case of typhoid fever, with ever so much 
care, may be transmitted to neighbors. 

Third. All cities and towns should require, under a heavy and rigidly 
enforced penalty, every physician to report to the mayor or health officer every 
ease of typhoid coming under his professional care. For this report the city 
should furnish physicians with post cards prepared so that only a few blank 
spaces would have to be filled out for notification. As soon as a case was 
reported, the health officer should visit the home, and from some responsible 
person obtain the data necessary to fill out the following blank form: 

TYPHOID FEVER REGISTRATION BLANK. 
City Health Department. 

, N. C. 

Residence 

Physician's name and address 

Date of physician's report 

Character of house (private house, apartment, boarding house, hotel, etc.) .... 

Age Sex 

Occupation 

Place of business 

Where living month previous to illness? 



Absence from home previous to illness. 
If so, where? 



18 



Date of first symptom 

Date of taking bed 

Date of doctor's first call 

Date of leaving bed on recovery. 

Date of relapse 

Date of deatb 

Sanitary condition of premises. . 



Sources of drinking water — At home 

At business Elsewhere . 

Milk supply from 

Milk habitually drunk? 

Raw oysters eaten? Source 

Patient has separate room? Nurse? 

Were stools disinfected? The urine' 

Any other precautions taken? 



Other cases in house (obtain names and dates) 



Other cases among business associates. 

Schoolmates 

Friends 



Number of people in the house. 
Remarks 



Information given by. 

Information given to. 

Date of information.. 

(Signed). 



With these data, a map of the city in the mayor's office or city hall may 
have a tack (red tack for white, black tack for negro) stuck in it showing 
the location and race of each case. One could, with a glance at such a map, 
see whether the disease was uniformly distributed over the town. This would 
be the distribution if the disease were obtained through the public water 
supply, because nearly all the population is subject to this influence. On the 
other hand, if the disease were conveyed through milk, it would occur most 
abundantly in the well-to-do districts, as this class of the population use more 
milk than the poorer classes. A study of the registration blanks would show 



19 

the disease comparatively frequent among children, too, and if all the dairies 
were put down and each case charged to the dairyman on whose route it oc- 
curred, one dairyman would probably have 90 per cent of the cases to his 
credit. His dairy should be at once visited, the source of the epidemic found 
and removed. Lastly, if most of the cases were in a part of the town where 
there was no sewer system but many open privies, a condition often obtain- 
ing among the poorer classes of the population, we would suspect the flies and 
open privies. 

With the information obtained by the above method, epidemics would be 
detected in the very outset. The cause, with the data of all the cases, could 
be easily worked out and removed, and great financial losses from sickness 
prevented and many lives saved. 

To Handle ax Epidemic. 

The first step, when an epidemic is already in progress, will be to publish 
the following notice in conspicuous type in a prominent place in the local 
papers. It should also be placarded throughout the town: 

To the Citizens of .' 

Typhoid fever is epidemic in 

The Board of Health is investigating this 

epidemic to find its exact source. In the meantime, govern yourselves as 
follows: 

1. Typhoid fever is contracted solely by the mouth. If you do not put 
the poison of typhoid fever into your mouth, you will never contract typhoid 
fever. Therefore, watch your mouth. 

2. Do not eat or drink anything (water, milk, oysters, fresh vegetables 
or anything else) unless it has been first boiled, broiled, baked, roasted, fried 
or otherwise thoroughly heated through and through. 

3. Do without all food or drink which has not first been thus heated. 
(Canned or bottled foods or drinks, other than milk or water, are not included 
in this.) 

4. If living in the same house with a typhoid fever patient, do not 
handle your own food, or food intended for any one else, even if it has been 
heated, except with hands that have been thoroughly washed with soap and 
very hot water. (Preferably also with antiseptic — ask your physician about 
the antiseptic to use.) Wash before every meal in this way and before 
cooking, serving or eating anything or putting the fingers in the mouth. 

5. If there are flies about, see that all food and drink is protected from 
them at all times. Plies often carry typhoid poison to foods and drinks. 

6. The poison of typhoid fever does not show itself for two weeks after 
it enters the body. Therefore, for the next two weeks typhoid cases may 
develop from typhoid poison already taken in. But any case which develops 
on and after (a date two weeks later than the date of the placard) will be due 
solely to neglect of this notice and failure to carry out minutely the direc- 
tions here given. 

The second step is to have the local profession called together, either by 
the president of the local society or by the mayor of the town. At this meet- 
ing the health officer should secure from the doctors the addresses of every 



20 

case of typhoid fever treated by them during the last six months. These ad- 
dresses should then be visited and a registration blank of the above form filled 
out for each case. Of course, if registration has been enforced these blanks 
will already be on hand at the city office and the second step will therefore 
be omitted, saving that much time and probably several lives. Indeed, if 
registration is practiced, any epidemic will be unlikely. With the registra- 
tion blanks on hand and a city map depicting the distribution of the cases, it 
will be easy to find out what common causative factor is related to 90 or 95 
per cent of the cases. With our attention once focussed on the most proba- 
ble sources, it is usually easy to find the cause and remove it, thereby ending 
the epidemic. 

While the investigation is going on, advantage should be taken of the 
temporary interest in the disease. This pamphlet, furnished in any quantity, 
by the State Board of Health, or other similar literature, should be distributed 
by drug stores, by the health department, by women's clubs, and other 
agencies. Newspaper articles (short so that they will be read) should be 
furnished the local papers. If possible, one or two addresses on the disease 
might be made. Remember, that public health work is an educational work, 
and strike the iron while it is red. 



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